Healthcare Provider Details

I. General information

NPI: 1033745344
Provider Name (Legal Business Name): KATIE PARK SIEGEL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11246 SULLIVAN ST
RIVERVIEW FL
33578-2140
US

IV. Provider business mailing address

10623 CARDERA DR
RIVERVIEW FL
33578-4705
US

V. Phone/Fax

Practice location:
  • Phone: 813-530-0111
  • Fax:
Mailing address:
  • Phone: 443-883-6402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN26203
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: